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<head>
<title>B.Tech Application offline- FISAT</title>
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function askforsubmit()
{

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}
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</script>
</head>
<body topmargin="0" leftmargin="0">
<center>

<div  class="appform">

	<form name="application" method="POST" action="/offline">
	<table border="0" cellpadding="4" cellspacing="1"  bgcolor="#005C1F" width="80%" >
	<tbody>
	<tr><td colspan=2><h1>FISAT Admission 2012(offline) <br><font size=4>Application for admission to B.Tech courses -Management Quota</font> </h1></td><tr>
	<tr bgcolor="white"><td bgcolor="white" colspan="2">&nbsp;</td><tr>
<tr><td colspan=2><div><span class="error">{{formerror.error}}</span></div><td></tr>	

<tr ><td bgcolor="#005C1F" >Personal Information</td><tr>

	<tr bgcolor="white"><td class="label">&nbsp;Name<font size="2" color="#FF0000" ><br>(as entered in the SSLC/10th certificate and without "." symbol)</font></td><td><input type="text" id="name" name="name" class="input" size="45" maxlength="100" tabindex=1><span class="error">{{forme.name}}</span></td></tr>

<tr bgcolor="white"><td class="label">&nbsp;Permanent Address<br><font size=2>(with pin code)</font></td><td><textarea rows="3" cols="55"  class="input" name="paddress" id="paddress" tabindex=2 ></textarea><span class="error">{{forme.paddress}}</span></td> </tr>
<tr bgcolor="white"><td class="label">&nbsp;Phone Numbers<font size="2" ><br>(with STD code)</font></td><td>Residential Phone&nbsp;&nbsp;<input type="text" name="resphone" id="resphone" class="input" size="15" maxlength="15" tabindex=3><span class="error">{{forme.resphone}}</span><br>Mobile Phone&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input type="text" name="mobphone" id="mobphone" class="input" size="15" maxlength="15"tabindex=4 ><span class="error">{{forme.mobphone}}</span></td></tr>
<tr bgcolor="white"><td class="label">Panchayath/City&nbsp;</td>
		<td>
		<select id="panchayath" name="panchayath" tabindex=5 size="1" class="select" onchange="checkOthers(1);">
			<option value="0">--Select--</option>
			<option value="MKR">Mookkannoor</option>
			<option value="Others">Others</option>
			
		</select>
		&nbsp;&nbsp;
		If others,Specify &nbsp;<input id="inpanchayath"  class="input" disabled name="inpanchayath" size="25" tabindex=6>
</td></tr>
<tr bgcolor="white"><td class="label">&nbsp;Address for communication<br><font size=2>(with pin code)</font></td><td>Same as permanent address &nbsp;<input type="checkbox" onclick="enableAddress(3);" name="samepaddress" id="samepaddress" value="ON" tabindex=7><br><textarea rows="3" cols="55"  class="input" name="caddress" id="caddress" tabindex=8></textarea><span class="error">{{forme.caddress}}</span></td> </tr>

<tr bgcolor="white"><td class="label">&nbsp;Email</td><td><input type="text" id="email" name="email" class="input" size="45" maxlength="100" tabindex=9><span class="error">{{forme.email}}</span></td></tr>

<tr bgcolor="white"><td class="label">&nbsp;Date of Birth</td><td>
		<table >
								<tr>
									<td><font size="2">Date&nbsp;
										<select name="dobdate" id="dobdate" tabindex="10" size="1" class="select" tabindex=10>
											
													<option value="01">01</option>														
													<option value="02">02</option>														
													<option value="03">03</option>									
													<option value="04">04</option>														
													<option value="05">05</option>														
													<option value="06">06</option>														
													<option value="07">07</option>														
													<option value="08">08</option>														
													<option value="09">09</option>														
													<option value="10">10</option>														
													<option value="11">11</option>														
													<option value="12">12</option>														
													<option value="13">13</option>														
													<option value="14">14</option>														
													<option value="15">15</option>														
													<option value="16">16</option>														
													<option value="17">17</option>														
													<option value="18">18</option>														
													<option value="19">19</option>														
													<option value="20">20</option>														
													<option value="21">21</option>														
													<option value="22">22</option>														
													<option value="23">23</option>														
													<option value="24">24</option>														
													<option value="25">25</option>														
													<option value="26">26</option>														
													<option value="27">27</option>														
													<option value="28">28</option>														
													<option value="29">29</option>														
													<option value="30">30</option>														
													<option value="31">31</option>														
													</select></font></td>
												<td ><font size="2">Month&nbsp;
												<select name="dobmonth" id="dobmonth" size="1" class="select" tabindex=11>
																										
														<option value="01">Jan</option>														
														<option value="02">Feb</option>														
														<option value="03">Mar</option>														
														<option value="04">Apr</option>														
														<option value="05">May</option>														
														<option value="06">Jun</option>														
														<option value="07">Jul</option>														
														<option value="08">Aug</option>														
														<option value="09">Sep</option>														
														<option value="10">Oct</option>														
														<option value="11">Nov</option>														
														<option value="12">Dec</option>														
													</select></font>
												</td>
												<td >Year&nbsp;
                                                <font  size="2">
												&nbsp;<select name="dobyear" id="dobyear" size="1"  class="select" tabindex=12>
														
														<option value="1980">1980</option>
														<option value="1981">1981</option>
														<option value="1982">1982</option>
														<option value="1983">1983</option>
														<option value="1984">1984</option>
														<option value="1985">1985</option>
														<option value="1986">1986</option>
														<option value="1987">1987</option>
														<option value="1988">1988</option>
														<option value="1989">1989</option>
                                                        <option value="1990">1990</option>
                                                        <option value="1991">1991</option>
                                                        <option value="1992">1992</option>
                                                        <option value="1993">1993</option>
                                                        <option value="1994">1994</option>
                                                        <option value="1995">1995</option>
                                                        <option value="1996">1996</option>
                                                        <option value="1997">1997</option>
                                                        <option value="1998">1998</option>
														<option value="1999">1999</option>
														<option value="2000">2000</option>
													</select></font></td>
												</tr>
												</table></td>

		<tr bgcolor="white"><td class="label">&nbsp;Gender</td>
		<td>
		Male&nbsp;<input type="radio" name="gender" id="gender" value="M" class="input" tabindex=13>&nbsp;&nbsp;Female&nbsp;<input class="input" type="radio"  id="gender"   name="gender" value="F" tabindex=14>
		</td>

<tr bgcolor="white"><td class="label">&nbsp;Nationality</td><td><input type="text" id="nation" name="nation" class="input" size="20" maxlength="20" value="Indian" ><span class="error">{{forme.nation}}</span></td></tr>

		<tr bgcolor="white"><td class="label">&nbsp;Religion</td>
		<td>
		<select name="religion" id="religion" size="1" class="select">
			<option value="Hindu">Hindu</option>
			<option value="Christian">Christian</option>
			<option value="Muslim">Muslim</option>
			<option value="Others">Others</option>
		</select>
		&nbsp;&nbsp;
		&nbsp;Community&nbsp;<input class="input" name="caste"  id="caste" size="15">
		&nbsp;&nbsp;
		&nbsp;Category &nbsp;
		<select name="category" id="category" size="1" class="select">
			<option value="General">General</option>
			<option value="SC">SC</option>
			<option value="ST">ST</option>
			<option value="OEC">OEC</option>
			<option value="OBC">OBC</option>
			<option value="Others">Others</option>
		</select>
		</td></tr>

<tr bgcolor="white"><td class="label">Father's Details</td>
<td>
<table>
	<tr><td class="label" >&nbsp;Name&nbsp;<input type="text" name="fathername" id="fathername" class="input" size="45" maxlength="100" ><span class="error">{{forme.fathername}}</span><br></td></tr>
	<tr><td class="label">&nbsp;Occupation&nbsp;<input type="text"  name="fatherocc" id="fatherocc" class="input" size="39" maxlength="38" ></td><tr>	
	<tr><td class="label" >&nbsp;Employed &nbsp;<input type="checkbox" onclick="enableAddress(1);" name="fatheremployed" id="fatheremployed" value="YES"></td><tr>
	<tr><td class="label">&nbsp;Designation&nbsp;<input type="text" disabled name="fatherdesig" id="fatherdesig" class="input" size="39" maxlength="38" ></td><tr>
	<tr><td class="label" valign="top">&nbsp;Official Address <br><textarea  rows="3" cols="55"  disabled class="input" id="fatheraddress" name="fatheraddress"></textarea><span class="error">{{forme.fatheraddress}}</span><br>
<tr><td class="label">&nbsp;Office Phone No&nbsp;<input type="text" disabled name="fatherphone" id="fatherphone" class="input" size="15" maxlength="15" ></td><tr>
</table></td></tr>

<tr bgcolor="white"><td class="label">Mother's Details</td>
<td>
<table>
	<tr><td class="label" >&nbsp;Name&nbsp;<input type="text" name="mothername" id="mothername" class="input" size="45" maxlength="100" ><span class="error">{{forme.mothername}}</span><br></td></tr>
	<tr><td class="label">&nbsp;Occupation&nbsp;<input type="text"  name="motherocc" id="motherocc" class="input" size="39" maxlength="38" ></td><tr>	
	<tr><td class="label" >&nbsp;Employed &nbsp;<input type="checkbox" onclick="enableAddress(2);" name="motheremployed" id="motheremployed" value="YES"></td><tr>
	<tr><td class="label">&nbsp;Designation&nbsp;<input type="text" disabled name="motherdesig" id="motherdesig" class="input" size="39" maxlength="38" ></td><tr>
	<tr><td class="label" valign="top">&nbsp;Official Address <br><textarea  rows="3" cols="55"  disabled class="input" id="motheraddress" name="motheraddress"></textarea><span class="error">{{forme.motheraddress}}</span><br>
<tr><td class="label">&nbsp;Office Phone No&nbsp;<input type="text" disabled name="motherphone" id="motherphone" class="input" size="15" maxlength="15" ></td><tr>
</table></td></tr>

     


<tr bgcolor="white"><td class="label">&nbsp;Whether Mother/Father/Grand parent is member of FBOAES</td><td>Yes&nbsp;<input type="checkbox" onclick="enableAddress(4);" name="enablemfboaes" id="enablemfboaes" value="ON">&nbsp;<br>Membership No&nbsp;&nbsp;<input class="input" disabled name="mfboaesmemno" id="mfboaesmemno"><span class="error">{{forme.mfboaesmemno}}</span></td> </tr>
 <tr>
<tr bgcolor="white"><td class="label">&nbsp;Whether Mother/Father/Grand parent is patron of FBOAES</td><td>Yes&nbsp;<input type="checkbox" onclick="enableAddress(5);" name="enablepfboaes" id="enablepfboaes" value="ON">&nbsp;<br>Membership  No&nbsp;&nbsp;<input class="input"disabled name="pfboaesmemno" id="pfboaesmemno"><span class="error">{{forme.pfboaesmemno}}</span></td> </tr>
 <tr>

<tr bgcolor="white"><td class="label">&nbsp;Annual Income</td><td>Rs&nbsp;<input type="text" id="income" name="income" class="input" size="20" maxlength="20" >/-<span class="error">{{forme.income}}</span></td></tr>


<tr><td bgcolor="#005C1F" >Academic Qualification</td><tr>

<tr bgcolor="white"><td class="label">Qualifying Examination Details(+2)&nbsp;</td>
<td>
<table>

		<tr><td colspan=2>	
		Year of passing &nbsp;<input id="qualexamyear"  class="input"  name="qualexamyear" size="4"><span class="error">{{forme.qualexamyear}}</span>
		<select id="qualexam" name="qualexam" size="1" class="select" onchange="checkOthers(2);">
			<option value="HSE">HSE</option>
			<option value="AISSCE">AISSCE(CBSE)</option>
			<option value="ICSE">ICSE</option>
			<option value="VHSE">VHSE</option>
			<option value="THSE">THSE</option>
			<option value="Others">Others</option>
		</select>&nbsp;&nbsp;If others,Specify &nbsp;<input id="inqualexam"  class="input" disabled name="inqualexam" size="15"><span class="error">{{forme.inqualexam}}</span>
		</td></tr>
		<tr><td colspan=2>Registration No&nbsp;&nbsp;<input type="text" name="qualexamno" id="qualexamno" class="input" size="45" maxlength="100" ><span class="error">{{forme.qualexamno}}</span></td></tr>
		<tr><td colspan=2>Board of Examination&nbsp;&nbsp; <input type="text" name="qualboard" id="qualboard" class="input" size="45" maxlength="100" ><span class="error">{{forme.qualboard}}</span></td></tr>
<tr><td >Physics</td><td>&nbsp;&nbsp;&nbsp;&nbsp;Mark(+2 only)&nbsp;&nbsp;<input name="qpmark" id="qpmark" class="input" size=4><span class="error">{{forme.qpmark}}</span>&nbsp;&nbsp;Maximum Mark&nbsp;&nbsp;<input name="qpmaxmark" id="qpmaxmark" class="input" size=4><span class="error">{{forme.qpmaxmark}}</span></td><tr>
<tr><td>Chemistry</td><td>&nbsp;&nbsp;&nbsp;&nbsp;Mark(+2 only)&nbsp;&nbsp;<input name="qcmark" id="qcmark" class="input" size=4><span class="error">{{forme.qcmark}}</span>&nbsp;&nbsp;Maximum Mark&nbsp;&nbsp;<input name="qcmaxmark" id="qcmaxmark" class="input" size=4><span class="error">{{forme.qcmaxmark}}</span></td></tr>
<tr><td>Maths</td><td>&nbsp;&nbsp;&nbsp;&nbsp;Mark(+2 only)&nbsp;&nbsp;<input name="qmmark" id="qmmark" class="input" size=4><span class="error">{{forme.qmmark}}</span>&nbsp;&nbsp;Maximum Mark&nbsp;&nbsp;<input name="qmmaxmark" id="qmmaxmark" class="input" size=4 ><span class="error">{{forme.qmmaxmark}}</span></td></tr>
</table>
</td></tr>

<tr bgcolor="white"><td class="label">&nbsp;Kerala Engg. Entrance Exam-2012  Details</td><td><table><tr><td >Roll No&nbsp;&nbsp;</td><td colspan=2>&nbsp;&nbsp;<input type="text" name="erollno" id="erollno" class="input" size="25" maxlength="25" ><span class="error">{{forme.erollno}}</span></td></tr><tr><td>Rank(If published)</td><td>&nbsp;&nbsp;<input type="text" name="erank" id="erank" class="input" size="25" maxlength="25" ><span class="error">{{forme.erank}}</span></td></tr>
<tr><td>Physics and Chemistry</td><td>&nbsp;&nbsp;&nbsp;&nbsp;Mark&nbsp;&nbsp;<input name="epcmark" id="epcmark" class="input" size=8>&nbsp;&nbsp;<span class="error">{{forme.epcmark}}</span>&nbsp;&nbsp;Maximum Mark&nbsp;&nbsp;<input name="epcmaxmark" id="epcmaxmark"  class="input" size=4><span class="error">{{forme.epcmaxmark}}</span></td><tr>
<tr><td>Maths</td><td>&nbsp;&nbsp;&nbsp;&nbsp;Mark&nbsp;&nbsp;<input name="emmark" id="emmark" class="input" size=8>&nbsp;&nbsp;<span class="error">{{forme.emmark}}</span>&nbsp;&nbsp;Maximum Mark&nbsp;&nbsp;<input name="emmaxmark" id="emmaxmark" class="input" size=4  ><span class="error">{{forme.emmaxmark}}</span></td><tr>
</table></td></tr>

<tr bgcolor="white"><td class="label">&nbsp;Name and address of the school/institution last studied<br><font size=2>(with pin code)</font></td><td><textarea rows="3" cols="55"  class="input" name="insaddress" id="insaddress"></textarea><span class="error">{{forme.insaddress}}</span><br>&nbsp;&nbsp;Phone No<input type="text" name="insphone" id="insphone" class="input" size="15" maxlength="15" ><span class="error">{{forme.insphone}}</span>
</td> </tr>



<tr><td bgcolor="#005C1F" >Branch Preferences</td><tr>
<tr bgcolor="white"><td class="label">Select the order of preference of branches offered.<br>All choices are mandatory&nbsp;</td>
		<td>&nbsp;Choice 1.&nbsp;&nbsp;
		<select id="bp1" name="bp1" size="1" class="select"">
			<option value="0">--Select--</option>
			<option value="ECE">Electronics & Communication Engg. (ECE)</option>
			<option value="CSE">Computer Science & Engg. (CSE)</option>
			<option value="EEE">Electrical & Electronics Engg. (EEE)</option>
			<option value="EIE"> Electronics & Instrumentation Engg. (EIE)</option>
			<option value="ME">Mechanical Engg. (ME)</option>
			<option value="CE">Civil Engg. (CE)</option>
		</select><span class="error">{{forme.bp1}}</span><br>
			&nbsp;Choice 2.&nbsp;&nbsp;
		<select id="bp2" name="bp2" size="1" class="select"">
			<option value="0">--Select--</option>
			<option value="ECE">Electronics & Communication Engg. (ECE)</option>
			<option value="CSE">Computer Science & Engg. (CSE)</option>
			<option value="EEE">Electrical & Electronics Engg. (EEE)</option>
			<option value="EIE"> Electronics & Instrumentation Engg. (EIE)</option>
			<option value="ME">Mechanical Engg. (ME)</option>
			<option value="CE">Civil Engg. (CE)</option>
		</select><span class="error">{{forme.bp2}}</span><br>
			&nbsp;Choice 3.&nbsp;&nbsp;
		<select id="bp3" name="bp3" size="1" class="select"">
			<option value="0">--Select--</option>
			<option value="ECE">Electronics & Communication Engg. (ECE)</option>
			<option value="CSE">Computer Science & Engg. (CSE)</option>
			<option value="EEE">Electrical & Electronics Engg. (EEE)</option>
			<option value="EIE"> Electronics & Instrumentation Engg. (EIE)</option>
			<option value="ME">Mechanical Engg. (ME)</option>
			<option value="CE">Civil Engg. (CE)</option>
		</select><span class="error">{{forme.bp3}}</span><br>
			&nbsp;Choice 4.&nbsp;&nbsp;
		<select id="bp4" name="bp4" size="1" class="select"">
			<option value="0">--Select--</option>
			<option value="ECE">Electronics & Communication Engg. (ECE)</option>
			<option value="CSE">Computer Science & Engg. (CSE)</option>
			<option value="EEE">Electrical & Electronics Engg. (EEE)</option>
			<option value="EIE"> Electronics & Instrumentation Engg. (EIE)</option>
			<option value="ME">Mechanical Engg. (ME)</option>
			<option value="CE">Civil Engg. (CE)</option>
		</select><span class="error">{{forme.bp4}}</span><br>
			&nbsp;Choice 5.&nbsp;&nbsp;
		<select id="bp5" name="bp5" size="1" class="select"">
			<option value="0">--Select--</option>
			<option value="ECE">Electronics & Communication Engg. (ECE)</option>
			<option value="CSE">Computer Science & Engg. (CSE)</option>
			<option value="EEE">Electrical & Electronics Engg. (EEE)</option>
			<option value="EIE"> Electronics & Instrumentation Engg. (EIE)</option>
			<option value="ME">Mechanical Engg. (ME)</option>
			<option value="CE">Civil Engg. (CE)</option>
		</select><span class="error">{{forme.bp5}}</span><br>
			&nbsp;Choice 6.&nbsp;&nbsp;
			<select id="bp6" name="bp6" size="1" class="select"">
			<option value="0">--Select--</option>
			<option value="ECE">Electronics & Communication Engg. (ECE)</option>
			<option value="CSE">Computer Science & Engg. (CSE)</option>
			<option value="EEE">Electrical & Electronics Engg. (EEE)</option>
			<option value="EIE"> Electronics & Instrumentation Engg. (EIE)</option>
			<option value="ME">Mechanical Engg. (ME)</option>
			<option value="CE">Civil Engg. (CE)</option>
		</select><span class="error">{{forme.bp6}}</span><br>
</td></tr>

<tr><td bgcolor="#005C1F" >Additional Information</td><tr>
<tr bgcolor="white"><td class="label">&nbsp;Extra-curricular activities</td><td><textarea rows="3" cols="55"  class="input" name="extra" id="extra"></textarea></td> </tr>
<tr bgcolor="white"><td class="label">&nbsp;Additional Information, if any</td><td><textarea rows="3" cols="55"  class="input" name="addinfo" id="addinfo"></textarea></td> </tr>

<tr><td bgcolor="#005C1F" >Payment Information</td><tr>
<tr bgcolor="white"><td class="label">&nbsp;Demand Draft Details</td>
<td>
<table>
<tr><td class="label"">DD No</td><td><input name="ddno" id="ddno" class="input" size=12 ><span class="error">{{forme.ddno}}</span></td><td>Date(DD/MM/YYYY)</td><td><input name="dddate" id="dddate" class="input" size=10 ><span class="error">{{forme.dddate}}</span></td></tr>
<tr><td class="label">&nbsp;&nbsp;&nbsp;&nbsp;Bank</td><td><input name="ddbank" id="ddbank" class="input" size=20 maxsize=50><span class="error">{{forme.ddbank}}</span></td><td>Branch</td><td><input name="ddbranch" id="ddbranch" class="input" size=20 maxsize=50 ><span class="error">{{forme.ddbranch}}</span></td></tr>

</table>
</td></tr>

<tr bgcolor="#005C1F"><td align="center" colspan=2 class="button"><button type=button onclick="askforsubmit();">Submit Application </button></td> </tr>
</tbody> 
</table>
</form></div>
</center>
</body>	
</html>					
			
